A mother was left “terrified” to have further children after Kingston Hospital failed to properly investigate the death of her two-day-old son.

Alison Pantlin, 47, gave birth to Charlie on July 30, 2005 in Kingston Hospital, only for her new-born son to be taken to intensive care and die two days later, despite a “straightforward pregnancy”.

The family, now of East Sheen but who lived in Cobham at the time, had to wait 11 years for answers.

READ MORE: 'Staff couldn't wait for us to go': Woman in labour 'left alone' on understaffed Kingston Hospital ward before baby boy's unexplained death, inquest hears

Soon after leaving Kingston Hospital the parents began to question how long it took doctors to send Mrs Pantlin for a caesarean section.

The inquest heard how the pair had been “discouraged” from asking for a postmortem examination by doctors, meaning coroner Sean Cummings could only deliver a narrative verdict of Charlie likely dying from bleeding inside the skull.

The inquest heard how lead midwife Anna Kelly was having to administer care to Mrs Pantlin as well as manage the “possibly” understaffed ward.

An internal investigation by the Kingston Hospital NHS Foundation Trust finally took place in 2012 and found the head midwife should not have been administering care.

Speaking after the hearing, Mrs Pantlin, now a mother of two, said: “They appeared not to know how to deal with me at all. They wanted rid, you felt that they just wanted us to go.

“We discovered that they hadn’t done anything, it was as if the next day they had all just gone back to work.

“I think that’s what really hurts. Had they actually talked about what happened we probably wouldn’t have had to go through this process now.

“It’s caused me considerable anxiety on and off over the years. It’s affected the type of mother I am to my two boys.

“[I was] terrified something might happen to them. It made the first few weeks of my time very difficult.”

Surrey Comet:

Mrs Pantlin was admitted to the maternity ward in July 2005

Expert witness John Seaton was “not critical” of the care Mrs Pantlin received during her time on the ward, but the coroner noted numerous witnesses who highlighted the hospital’s failure to properly investigate up until 2012.

Andrew Pooley, 47, consultant obstetrician and gynaecologist at Kingston Hospital, said: “The advice still says that the lead midwife should not be involved. 

“There should not have been a prolonged period of time where the lead midwife was giving one-to-one care.

“I’m certainly upset that this sort of event has happened.”

Michael and Alison Pantlin were still not satisfied with the investigation and soon after wrote to the coroner’s office requesting a full inquest.

Mr Pantlin said: “We were never strong enough before 2012 to face the music in a way. We had pondered over the time it took to decide for a caesarean section.

“We feel the narrative verdict supports our view as best as it probably can. It was the first time that someone of a position of authority was prepared to listen.

“[Kingston Hospital] still haven’t asked to this day how has this happened.”

A red, amber and green system is now in place so hospital staff can call in off-duty midwives if the ward is overstretched, with ambulances diverted to other hospitals in extreme circumstances.

Earlier this year, the Red Cross said the NHS was on the verge of a “humanitarian crisis” due to overcrowded hospitals.

Mr Cummings said he could “not be sure” if any hospital worker’s actions resulted in Charlie’s death in his conclusion.

He said: “There are constraints on me on what I can do and what I can’t do and however much a coroner may sympathise with families and the deceased I still need to stick within the law.

“Charlie James Pantlin died following delivery. I’ve heard evidence from two expert witnesses that intracranial haemorrhage was the more likely cause of death.”

A Kingston Hospital NHS Foundation Trust spokewoman said: “We are very sorry about Charlie's unexpected and tragic death. We recognise that it should have been thoroughly investigated at the time and we are sincerely sorry that it was not.

"We now have robust and very well embedded mechanisms in place to ensure that such a failure to investigate would not happen again.”